Created by Nell Osborne
Salamander Trust Associate
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Dear Friends, 

One month ago in Melbourne, Australia the 20th International AIDS Conference was under way. Over 13,000 activists, scientists, policy makers and healthcare professionals came together to present, learn and share knowledge.

Here is a Stepping Stones summary of some of the key themes and topics, challenges and research findings for those who weren’t able to attend the conference:
Working towards a cure…
There is still no cure or vaccine available for HIV, although research continues.
Much of the discussion about an HIV cure focused around the ‘Mississippi baby.’ This refers to a baby born with HIV in North America who was quickly started on antiretroviral treatment. The child was taken off treatment and for two years no tests were able to detect the virus in her body. As a result many doctors and scientists believed that she had been cured of the HIV virus.

However, it was recently discovered that early treatment did not cure the HIV virus but simply suppressed the presence of the virus in her body for a long time, so that it was undetectable to all tests. This means that the ‘Mississippi baby’ was never actually “cured” of HIV. This came as a disappointment to many people. However, scientists at the conference have said that the research has still helped to move them forwards and they have learnt more about how the virus works in the human body. For example, AIDS 2014 co-chair, Sharon Lewin, said that in the future, HIV may be talked about in a way more similar to cancer. Thus we might talk more about remission periods rather than a cure for people living with HIV.
Many people were talking about PrEP (short for Pre-Exposure Prophylaxis). This is a pill, that taken every day, can help prevent a person from acquiring HIV, even when exposed. It has been suggested as a preventative measure for those people who are HIV negative. It must also be used with a condom every time, to avoid STIs or unplanned pregnancy.

When taken consistently, PrEP has been shown to reduce the risk of acquiring HIV in people who are at high risk by up to 92%. However, when not taken consistently it is much less effective. It also comes with its own challenges – which were the focus of many talks at the conference. The long term health problems of taking it daily are not fully known, negative short term side-effects may mean that people don’t take the pills consistently or that they stop taking them. Another worry is that people may stop using other preventative measures (such as condoms) in a way that puts them at a greater risk of contracting HIV or other STIs – or unplanned pregnancy -  if they are taking PrEP. 
Decriminalising Sex Work
Research released at the conference claims that the decriminalisation of sex work would have the greatest impact on the course of HIV epidemics by “averting 33-46% of HIV infections in the next decade."

Diasy Nakato, a sex worker from Uganda, and founder of WOENTHA, global network of sex work projects presented a plenary speech calling for the meaningful involvement of women who do sex work in HIV programmes. You can watch her speech here.
Gender Based Violence and HIV
The presence of gender-based violence in healthcare settings was another big theme of the conference. In Thailand we heard how women who use drugs are being turned away from health services, due to gender discrimination whilst coerced sterilization of women living with HIV was shown to be happening in many different countries, from Namibia to Mexico. 

Research from Tamil Kendall in El Salvador, Honduras, Mexico and Nicaragua showed that, in some counties, up to 25% of women living with HIV had experienced pressure from healthcare providers to sterilise since their HIV diagnosis. In response to this research, there was a call to ensure that human rights are central to all health care services. Dr Lydia Mungherera from Uganda used her plenary speech to call for an end of all forms of discrimination and stigma that occur in healthcare settings. “We need to give hope and dignity to women living with HIV”. Click here to watch her speech in full.

Prevention of transmission to babies has also become central to the current HIV response agenda. But research by Lyson Tenthani and colleagues, shared during the conference, has shown that women with HIV placed on Option B+ - ie starting ART for life in pregnancy - were 5 times more likely to be “lost to follow-up” than patients initiating treatment when their CD4 count dropped below 350. The researchers argue that this highlights the urgent need for comprehensive treatment literacy, preparation and support for the women. We also heard how peer support networks, such as Mama’s Club in Uganda, and the From Pregnancy to Baby and Beyond programme in the UK, can help support women to adhere to treatment during pregnancy and, if they need it for themselves - afterwards. This is especially important to avoid future increases in people living with drug resistant HIV – which can be an unwelcome side-effect of only taking medication intermittently.

However it was clear from the many stories that were being told by women living with HIV at the conference that gender-based violence remains a key challenge for women trying to access and adhere to ARTResearch undertaken in 2012 by the Coalition of Women Living with HIV and AIDS in Malawi (COWLHA) found that 'refusal to continue ART' and 'inconsistency in following ART guidelines' were two of the leading consequences of inter-personal violence within households. Despite this, the impact of gender based violence on treatment access and adherence was still not widely addressed during the 2014 conference.

There were other debates about how to safely and effectively encourage male involvement in peri-natal services. We heard a call from activists to start calling them PPCT services - Prevention of Parent to child transmission! However there remains a question mark over how best to incorporate male partners into these services, whilst upholding the rights of women to be in the driving seat around their pregnancy and delivery.
Key Populations
Reducing HIV transmission among people who use drugs was a top priority at the conference. HIV prevalance amongst people who inject drugs is 22 times higher than in the general population. The situation is particularly bad in Eastern Europe and South-West Asia - but there was also shown to be high levels of drug use in parts of East Africa.

Despite this generalised attention, only 2/31 sessions about drug use and HIV focused specifically on women who use drugs. Silvia Petretti argues that women who use drugs have specific vulnerabilities to HIV, as a result of gender inequality, which is still being largely ignored by researchers and policy makers.

The Melbourne conference was the first AIDS conference to host a transgender networking zone, to focus specifically on the needs of transgender communities. Transgender women are 50 times more likely than the general population to contract HIV.

We also heard about the disproportionate impact of HIV on indigenous communities, in Australia and beyond. Click here to watch a plenary speech given by James Ward.

The conference also saw a big call for all governments to abandon all anti-homosexuality laws, which are preventing people from safely accessing HIV treatment, care and support. Sheree Schwartz presented research that showed how, as a result of anti homosexuality laws introduced earlier this year in Nigeria, men who have sex with men were between 10 % and 15% less likely to seek medical testing and treatment out of fear of arrest, beatings and blackmail.
One form of violence highlighted during the conference was stigma. The creation of a Melbourne Declaration calling for an End to Stigma and Discrimination was endorsed by thousands of conference delegates. Click here to read more about the declaration and to sign up. This included a call for an end to laws, which criminalise HIV transmission, homosexuality, transgender communities and sex work.

Virginia Bond presented her research about community understanding of HIV prevention strategies and found global emphasis on treatment as prevention has shifted the responsibility for HIV prevention onto people living with HIV. “Rather than linking treatment to prevention so strongly I think we should build on them as separate programs.” She advocated for people to communicate better about HIV prevention so that blame and burden does not only fall with those people who know that they are living with HIV.

Martha Tholanah from Zimbabwe has written a great article about the importance of challenging the stigma of our politicians, policy makers and academics. Her perspective from Zimbabwe has highlighted the stigma that is present in discussions about when to disclose HIV status to a child. They often focus, she says, on whether a child is too young to understand, or too immature to handle the knowledge. However, this disguises the real problematic issue, which is that HIV stigma in our communities remains high, despite medical advances.

“Surely therefore what decision-makers should be asking, instead of “when to disclose to a child?” is “how to overcome the stigmatising attitudes we as health providers and law-makers hold and convey?” 

A joint poster about the Stepping Stones With Children adaptation, which was presented at the conference highlighted the importance of honest communication around issues of HIV for orphans affected by HIV (See below for information and a photo).
Treatment Access
HIV Self-Testing looks set to become a reality in the future. Strategies that increase testing among the population are very important, as over half of people living with HIV are unaware of their status. A UNAIDS report shows that 19 million of the 35 million people living with HIV today do not know that they have the virus. It is hoped that self-testing would allow people to test, even in areas where they are unable to or where they do not feel safe to use health care testing facilities.

However, there are still some key questions about how best to integrate self- testing with pre- and post-test counselling, which is especially important for emotional wellbeing if a positive diagnosis is received. Research has already highlighted the importance of gender and power dynamics, with 3% of participants reporting being coerced into self-testing by their partner.

UNAIDS also used the conference to announce its new goal to end AIDS in cities by 2030. To do this it has unveiled an ambitious “90-90-90” target.
·      Target 1: Increase the proportion of people with HIV who know their diagnosis to 90%
·      Target 2: Increase the proportion of people receiving antiretroviral treatment to 90%
·      Target 3: Increase the proportion of people under treatment who have an undetectable viral load

However, many people have raised doubts over whether this strategy is possible, without addressing wider social issues. There would need to be a huge new uptake of testing services for this strategy to be successful and key to increasing testing is tackling the fear or realities of violence and related gender inequalities that are preventing people from accessing services. It is still not clear how this will be addressed by the UNAIDS strategy.
Keeping HIV on the political Agenda
The conference heard renewed calls to increase funding for the response to HIV care, treatment, prevention and support. Speakers and activists called on governments to maintain their commitment to the Global Fund to fight AIDS, tuberculosis and malaria.
However, Kaiser Family Foundation President and CEO Drew Altman has shown how funding has flattened since the worldwide recession and fears that it is “likely to remain flat for the immediate future.” This is worrying news as many delegates feel that without funding at this critical point in history, we will not be able to provide quality care, treatment and support for those people already living with HIV, or to successfully prevent more people from acquiring HIV. 
The International AIDS Conference 2014 was a great year for Stepping Stones! We even heard one delegate comment that: 
“Everyone is talking about Stepping Stones!”
Stepping Stones in Malawi, Tanzania and South Africa at AIDS 2014

Stepping Stones featured in a presentation by Annie Banda, Director of COWLHA, Malawi at a session at the Melbourne AIDS Conference. To hear and see her presentation, click here.

Stepping Stones work with children and their caregivers, led by our partner PASADA in Dar es Salaam featured on a poster at AIDS 2014. To view information about this poster click here.

South Africa: 
Andrew Gibbs of the University of Kwa-Zulu Natal Heard presented in a session on Addressing Gender Concerns: Violence and HIV. His presentation, which can be viewed here shared findings of the recent "Stepping Stones and Creating Futures" livelihoods programme formative evaluation, by HEARD, MRC S. Africa and Project Empower in S. Africa. To view the abstract, click here.  To read more about the Creating Futures programme, view our Stepping Stones newsletter here.
Stepping Stones Around the World: Global Photo Exhibition at AIDS 2014
Nell Osborne also curated a photo exhibition of Stepping Stones around the world at AIDS 2014. This was featured in the Global Village. 

Thanks for reading!
If you have questions or comments about any of the topics above, get in contact at:
Copyright © 2014 Salamander Trust, All rights reserved.

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